|
MASTOPEXY - FULL
|
Professional
|
Both
|
$1,250.00
|
|
| Hospital Charge Code |
22200054
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$437.50 |
| Max. Negotiated Rate |
$875.00 |
| Rate for Payer: Cash Price |
$625.00
|
| Rate for Payer: Multiplan PHCS |
$750.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$875.00
|
| Rate for Payer: UHCCP Medicaid |
$437.50
|
|
|
MASTOPEXY - FULL
|
Facility
|
OP
|
$1,250.00
|
|
| Hospital Charge Code |
22200054
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$375.00 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$962.50
|
| Rate for Payer: Anthem Medicaid |
$429.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$975.00
|
| Rate for Payer: Cash Price |
$625.00
|
| Rate for Payer: Cigna Commercial |
$1,037.50
|
| Rate for Payer: First Health Commercial |
$1,187.50
|
| Rate for Payer: Humana Commercial |
$1,062.50
|
| Rate for Payer: Humana KY Medicaid |
$429.88
|
| Rate for Payer: Kentucky WC Medicaid |
$434.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,025.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$922.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$375.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$438.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,100.00
|
| Rate for Payer: Ohio Health Group HMO |
$937.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$862.50
|
| Rate for Payer: PHCS Commercial |
$1,200.00
|
| Rate for Payer: United Healthcare All Payer |
$1,100.00
|
|
|
MASTOPEXY - FULL
|
Facility
|
IP
|
$1,250.00
|
|
| Hospital Charge Code |
22200054
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$375.00 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$962.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$975.00
|
| Rate for Payer: Cash Price |
$625.00
|
| Rate for Payer: Cigna Commercial |
$1,037.50
|
| Rate for Payer: First Health Commercial |
$1,187.50
|
| Rate for Payer: Humana Commercial |
$1,062.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,025.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$922.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$375.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,100.00
|
| Rate for Payer: Ohio Health Group HMO |
$937.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$862.50
|
| Rate for Payer: PHCS Commercial |
$1,200.00
|
| Rate for Payer: United Healthcare All Payer |
$1,100.00
|
|
|
MASTOPEXY-FULL -80
|
Facility
|
OP
|
$625.00
|
|
| Hospital Charge Code |
22200380
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$187.50 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna Commercial |
$481.25
|
| Rate for Payer: Anthem Medicaid |
$214.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$487.50
|
| Rate for Payer: Cash Price |
$312.50
|
| Rate for Payer: Cigna Commercial |
$518.75
|
| Rate for Payer: First Health Commercial |
$593.75
|
| Rate for Payer: Humana Commercial |
$531.25
|
| Rate for Payer: Humana KY Medicaid |
$214.94
|
| Rate for Payer: Kentucky WC Medicaid |
$217.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$512.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$461.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$187.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$219.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$550.00
|
| Rate for Payer: Ohio Health Group HMO |
$468.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$543.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$431.25
|
| Rate for Payer: PHCS Commercial |
$600.00
|
| Rate for Payer: United Healthcare All Payer |
$550.00
|
|
|
MASTOPEXY-FULL -80
|
Facility
|
IP
|
$625.00
|
|
| Hospital Charge Code |
22200380
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$187.50 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna Commercial |
$481.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$487.50
|
| Rate for Payer: Cash Price |
$312.50
|
| Rate for Payer: Cigna Commercial |
$518.75
|
| Rate for Payer: First Health Commercial |
$593.75
|
| Rate for Payer: Humana Commercial |
$531.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$512.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$461.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$187.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$550.00
|
| Rate for Payer: Ohio Health Group HMO |
$468.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$543.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$431.25
|
| Rate for Payer: PHCS Commercial |
$600.00
|
| Rate for Payer: United Healthcare All Payer |
$550.00
|
|
|
MASTOPEXY-FULL -80
|
Professional
|
Both
|
$625.00
|
|
| Hospital Charge Code |
22200380
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$218.75 |
| Max. Negotiated Rate |
$437.50 |
| Rate for Payer: Cash Price |
$312.50
|
| Rate for Payer: Multiplan PHCS |
$375.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$437.50
|
| Rate for Payer: UHCCP Medicaid |
$218.75
|
|
|
MASTOPEXY(P
|
Professional
|
Both
|
$2,100.00
|
|
|
Service Code
|
HCPCS 19316
|
| Hospital Charge Code |
761P0306
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$698.93 |
| Max. Negotiated Rate |
$1,260.00 |
| Rate for Payer: Aetna Commercial |
$1,132.21
|
| Rate for Payer: Ambetter Exchange |
$749.40
|
| Rate for Payer: Anthem Medicaid |
$698.93
|
| Rate for Payer: Buckeye Individual/Medicaid |
$749.40
|
| Rate for Payer: Buckeye Medicare Advantage |
$749.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$899.28
|
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: Cigna Commercial |
$1,087.07
|
| Rate for Payer: Healthspan PPO |
$905.31
|
| Rate for Payer: Humana Medicaid |
$698.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$991.92
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$749.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$749.40
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$712.91
|
| Rate for Payer: Molina Healthcare Passport |
$698.93
|
| Rate for Payer: Multiplan PHCS |
$1,260.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$974.22
|
| Rate for Payer: UHCCP Medicaid |
$735.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$705.92
|
| Rate for Payer: Wellcare Medicare Advantage |
$749.40
|
|
|
MASTOTOMY WEXP OR DRAINABSCSDP
|
Facility
|
OP
|
$2,138.00
|
|
|
Service Code
|
HCPCS 19020
|
| Hospital Charge Code |
761T0276
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$735.26 |
| Max. Negotiated Rate |
$2,095.90 |
| Rate for Payer: Aetna Commercial |
$1,646.26
|
| Rate for Payer: Anthem Medicaid |
$735.26
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,497.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,667.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,095.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,021.04
|
| Rate for Payer: Cash Price |
$1,069.00
|
| Rate for Payer: Cash Price |
$1,069.00
|
| Rate for Payer: Cigna Commercial |
$1,774.54
|
| Rate for Payer: First Health Commercial |
$2,031.10
|
| Rate for Payer: Humana Commercial |
$1,817.30
|
| Rate for Payer: Humana KY Medicaid |
$735.26
|
| Rate for Payer: Humana Medicare Advantage |
$1,497.07
|
| Rate for Payer: Kentucky WC Medicaid |
$742.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,753.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,577.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,796.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$750.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,881.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,603.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,710.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,860.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,475.22
|
| Rate for Payer: PHCS Commercial |
$2,052.48
|
| Rate for Payer: United Healthcare All Payer |
$1,881.44
|
|
|
MASTOTOMY WEXP OR DRAINABSCSDP
|
Facility
|
OP
|
$2,138.00
|
|
|
Service Code
|
HCPCS 19020
|
| Hospital Charge Code |
45000084
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$735.26 |
| Max. Negotiated Rate |
$2,095.90 |
| Rate for Payer: Aetna Commercial |
$1,646.26
|
| Rate for Payer: Anthem Medicaid |
$735.26
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,497.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,667.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,095.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,021.04
|
| Rate for Payer: Cash Price |
$1,069.00
|
| Rate for Payer: Cash Price |
$1,069.00
|
| Rate for Payer: Cigna Commercial |
$1,774.54
|
| Rate for Payer: First Health Commercial |
$2,031.10
|
| Rate for Payer: Humana Commercial |
$1,817.30
|
| Rate for Payer: Humana KY Medicaid |
$735.26
|
| Rate for Payer: Humana Medicare Advantage |
$1,497.07
|
| Rate for Payer: Kentucky WC Medicaid |
$742.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,753.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,577.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,796.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$750.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,881.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,603.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,710.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,860.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,475.22
|
| Rate for Payer: PHCS Commercial |
$2,052.48
|
| Rate for Payer: United Healthcare All Payer |
$1,881.44
|
|
|
MASTOTOMY WEXP OR DRAINABSCSDP
|
Facility
|
IP
|
$2,138.00
|
|
|
Service Code
|
HCPCS 19020
|
| Hospital Charge Code |
45000084
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$641.40 |
| Max. Negotiated Rate |
$2,052.48 |
| Rate for Payer: Aetna Commercial |
$1,646.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,667.64
|
| Rate for Payer: Cash Price |
$1,069.00
|
| Rate for Payer: Cigna Commercial |
$1,774.54
|
| Rate for Payer: First Health Commercial |
$2,031.10
|
| Rate for Payer: Humana Commercial |
$1,817.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,753.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,577.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$641.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,881.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,603.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,710.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,860.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,475.22
|
| Rate for Payer: PHCS Commercial |
$2,052.48
|
| Rate for Payer: United Healthcare All Payer |
$1,881.44
|
|
|
MASTOTOMY WEXP OR DRAINABSCSDP
|
Professional
|
Both
|
$538.00
|
|
|
Service Code
|
HCPCS 19020
|
| Hospital Charge Code |
761P0276
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$143.24 |
| Max. Negotiated Rate |
$476.85 |
| Rate for Payer: Aetna Commercial |
$406.37
|
| Rate for Payer: Ambetter Exchange |
$295.95
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$161.09
|
| Rate for Payer: Anthem Medicaid |
$143.24
|
| Rate for Payer: Buckeye Individual/Medicaid |
$295.95
|
| Rate for Payer: Buckeye Medicare Advantage |
$295.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$355.14
|
| Rate for Payer: Cash Price |
$269.00
|
| Rate for Payer: Cash Price |
$269.00
|
| Rate for Payer: Cigna Commercial |
$376.07
|
| Rate for Payer: Healthspan PPO |
$476.85
|
| Rate for Payer: Humana Medicaid |
$143.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$373.11
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$295.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$295.95
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$146.10
|
| Rate for Payer: Molina Healthcare Passport |
$143.24
|
| Rate for Payer: Multiplan PHCS |
$322.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$384.74
|
| Rate for Payer: UHCCP Medicaid |
$169.14
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$144.67
|
| Rate for Payer: Wellcare Medicare Advantage |
$295.95
|
|
|
MASTOTOMY WEXP OR DRAINABSCSDP
|
Facility
|
OP
|
$2,676.00
|
|
|
Service Code
|
HCPCS 19020
|
| Hospital Charge Code |
76100276
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$920.28 |
| Max. Negotiated Rate |
$2,568.96 |
| Rate for Payer: Aetna Commercial |
$2,060.52
|
| Rate for Payer: Anthem Medicaid |
$920.28
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,497.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,087.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,095.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,021.04
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$2,221.08
|
| Rate for Payer: First Health Commercial |
$2,542.20
|
| Rate for Payer: Humana Commercial |
$2,274.60
|
| Rate for Payer: Humana KY Medicaid |
$920.28
|
| Rate for Payer: Humana Medicare Advantage |
$1,497.07
|
| Rate for Payer: Kentucky WC Medicaid |
$929.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,194.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,974.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,796.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$938.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,354.88
|
| Rate for Payer: Ohio Health Group HMO |
$2,007.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,140.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,328.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,846.44
|
| Rate for Payer: PHCS Commercial |
$2,568.96
|
| Rate for Payer: United Healthcare All Payer |
$2,354.88
|
|
|
MASTOTOMY WEXP OR DRAINABSCSDP
|
Facility
|
IP
|
$2,676.00
|
|
|
Service Code
|
HCPCS 19020
|
| Hospital Charge Code |
76100276
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$802.80 |
| Max. Negotiated Rate |
$2,568.96 |
| Rate for Payer: Aetna Commercial |
$2,060.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,087.28
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$2,221.08
|
| Rate for Payer: First Health Commercial |
$2,542.20
|
| Rate for Payer: Humana Commercial |
$2,274.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,194.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,974.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$802.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,354.88
|
| Rate for Payer: Ohio Health Group HMO |
$2,007.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,140.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,328.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,846.44
|
| Rate for Payer: PHCS Commercial |
$2,568.96
|
| Rate for Payer: United Healthcare All Payer |
$2,354.88
|
|
|
MASTOTOMY WEXP OR DRAINABSCSDP
|
Professional
|
Both
|
$2,676.00
|
|
|
Service Code
|
HCPCS 19020
|
| Hospital Charge Code |
76100276
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$143.24 |
| Max. Negotiated Rate |
$1,605.60 |
| Rate for Payer: Aetna Commercial |
$406.37
|
| Rate for Payer: Ambetter Exchange |
$295.95
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$161.09
|
| Rate for Payer: Anthem Medicaid |
$143.24
|
| Rate for Payer: Buckeye Individual/Medicaid |
$295.95
|
| Rate for Payer: Buckeye Medicare Advantage |
$295.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$355.14
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$376.07
|
| Rate for Payer: Healthspan PPO |
$476.85
|
| Rate for Payer: Humana Medicaid |
$143.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$373.11
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$295.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$295.95
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$146.10
|
| Rate for Payer: Molina Healthcare Passport |
$143.24
|
| Rate for Payer: Multiplan PHCS |
$1,605.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$384.74
|
| Rate for Payer: UHCCP Medicaid |
$169.14
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$144.67
|
| Rate for Payer: Wellcare Medicare Advantage |
$295.95
|
|
|
MASTOTOMY WEXP OR DRAINABSCSDP
|
Facility
|
IP
|
$2,138.00
|
|
|
Service Code
|
HCPCS 19020
|
| Hospital Charge Code |
761T0276
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$641.40 |
| Max. Negotiated Rate |
$2,052.48 |
| Rate for Payer: Aetna Commercial |
$1,646.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,667.64
|
| Rate for Payer: Cash Price |
$1,069.00
|
| Rate for Payer: Cigna Commercial |
$1,774.54
|
| Rate for Payer: First Health Commercial |
$2,031.10
|
| Rate for Payer: Humana Commercial |
$1,817.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,753.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,577.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$641.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,881.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,603.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,710.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,860.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,475.22
|
| Rate for Payer: PHCS Commercial |
$2,052.48
|
| Rate for Payer: United Healthcare All Payer |
$1,881.44
|
|
|
MATERNA 1:60 (PRENATAL VI 1TAB
|
Facility
|
IP
|
$4.23
|
|
|
Service Code
|
NDC 904531360
|
| Hospital Charge Code |
25000943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$4.06 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.30
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.51
|
| Rate for Payer: First Health Commercial |
$4.02
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.72
|
| Rate for Payer: Ohio Health Group HMO |
$3.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.92
|
| Rate for Payer: PHCS Commercial |
$4.06
|
| Rate for Payer: United Healthcare All Payer |
$3.72
|
|
|
MATERNA 1:60 (PRENATAL VI 1TAB
|
Facility
|
OP
|
$4.23
|
|
|
Service Code
|
NDC 904531360
|
| Hospital Charge Code |
25000943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$4.06 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem Medicaid |
$1.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.30
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.51
|
| Rate for Payer: First Health Commercial |
$4.02
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Humana KY Medicaid |
$1.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.72
|
| Rate for Payer: Ohio Health Group HMO |
$3.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.92
|
| Rate for Payer: PHCS Commercial |
$4.06
|
| Rate for Payer: United Healthcare All Payer |
$3.72
|
|
|
MATERNITY LEVEL 1 PER 15 MIN
|
Facility
|
IP
|
$661.00
|
|
| Hospital Charge Code |
36001263
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$198.30 |
| Max. Negotiated Rate |
$634.56 |
| Rate for Payer: Aetna Commercial |
$508.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$515.58
|
| Rate for Payer: Cash Price |
$330.50
|
| Rate for Payer: Cigna Commercial |
$548.63
|
| Rate for Payer: First Health Commercial |
$627.95
|
| Rate for Payer: Humana Commercial |
$561.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$542.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$487.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$198.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$581.68
|
| Rate for Payer: Ohio Health Group HMO |
$495.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$528.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$575.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$456.09
|
| Rate for Payer: PHCS Commercial |
$634.56
|
| Rate for Payer: United Healthcare All Payer |
$581.68
|
|
|
MATERNITY LEVEL 1 PER 15 MIN
|
Facility
|
OP
|
$661.00
|
|
| Hospital Charge Code |
36001263
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$198.30 |
| Max. Negotiated Rate |
$634.56 |
| Rate for Payer: Aetna Commercial |
$508.97
|
| Rate for Payer: Anthem Medicaid |
$227.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$515.58
|
| Rate for Payer: Cash Price |
$330.50
|
| Rate for Payer: Cigna Commercial |
$548.63
|
| Rate for Payer: First Health Commercial |
$627.95
|
| Rate for Payer: Humana Commercial |
$561.85
|
| Rate for Payer: Humana KY Medicaid |
$227.32
|
| Rate for Payer: Kentucky WC Medicaid |
$229.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$542.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$487.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$198.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$231.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$581.68
|
| Rate for Payer: Ohio Health Group HMO |
$495.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$528.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$575.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$456.09
|
| Rate for Payer: PHCS Commercial |
$634.56
|
| Rate for Payer: United Healthcare All Payer |
$581.68
|
|
|
MATERNITY LEVEL 2 PER 15 MIN
|
Facility
|
IP
|
$1,323.00
|
|
| Hospital Charge Code |
36001264
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$396.90 |
| Max. Negotiated Rate |
$1,270.08 |
| Rate for Payer: Aetna Commercial |
$1,018.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,031.94
|
| Rate for Payer: Cash Price |
$661.50
|
| Rate for Payer: Cigna Commercial |
$1,098.09
|
| Rate for Payer: First Health Commercial |
$1,256.85
|
| Rate for Payer: Humana Commercial |
$1,124.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,084.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$976.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$396.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,164.24
|
| Rate for Payer: Ohio Health Group HMO |
$992.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,058.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,151.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$912.87
|
| Rate for Payer: PHCS Commercial |
$1,270.08
|
| Rate for Payer: United Healthcare All Payer |
$1,164.24
|
|
|
MATERNITY LEVEL 2 PER 15 MIN
|
Facility
|
OP
|
$1,323.00
|
|
| Hospital Charge Code |
36001264
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$396.90 |
| Max. Negotiated Rate |
$1,270.08 |
| Rate for Payer: Aetna Commercial |
$1,018.71
|
| Rate for Payer: Anthem Medicaid |
$454.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,031.94
|
| Rate for Payer: Cash Price |
$661.50
|
| Rate for Payer: Cigna Commercial |
$1,098.09
|
| Rate for Payer: First Health Commercial |
$1,256.85
|
| Rate for Payer: Humana Commercial |
$1,124.55
|
| Rate for Payer: Humana KY Medicaid |
$454.98
|
| Rate for Payer: Kentucky WC Medicaid |
$459.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,084.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$976.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$396.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$464.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,164.24
|
| Rate for Payer: Ohio Health Group HMO |
$992.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,058.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,151.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$912.87
|
| Rate for Payer: PHCS Commercial |
$1,270.08
|
| Rate for Payer: United Healthcare All Payer |
$1,164.24
|
|
|
MATERNITY LEVEL 3 PER 15 MIN
|
Facility
|
IP
|
$1,984.00
|
|
| Hospital Charge Code |
36001265
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$595.20 |
| Max. Negotiated Rate |
$1,904.64 |
| Rate for Payer: Aetna Commercial |
$1,527.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,547.52
|
| Rate for Payer: Cash Price |
$992.00
|
| Rate for Payer: Cigna Commercial |
$1,646.72
|
| Rate for Payer: First Health Commercial |
$1,884.80
|
| Rate for Payer: Humana Commercial |
$1,686.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,626.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,464.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$595.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,745.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,488.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,587.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,726.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,368.96
|
| Rate for Payer: PHCS Commercial |
$1,904.64
|
| Rate for Payer: United Healthcare All Payer |
$1,745.92
|
|
|
MATERNITY LEVEL 3 PER 15 MIN
|
Facility
|
OP
|
$1,984.00
|
|
| Hospital Charge Code |
36001265
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$595.20 |
| Max. Negotiated Rate |
$1,904.64 |
| Rate for Payer: Aetna Commercial |
$1,527.68
|
| Rate for Payer: Anthem Medicaid |
$682.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,547.52
|
| Rate for Payer: Cash Price |
$992.00
|
| Rate for Payer: Cigna Commercial |
$1,646.72
|
| Rate for Payer: First Health Commercial |
$1,884.80
|
| Rate for Payer: Humana Commercial |
$1,686.40
|
| Rate for Payer: Humana KY Medicaid |
$682.30
|
| Rate for Payer: Kentucky WC Medicaid |
$689.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,626.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,464.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$595.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$695.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,745.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,488.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,587.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,726.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,368.96
|
| Rate for Payer: PHCS Commercial |
$1,904.64
|
| Rate for Payer: United Healthcare All Payer |
$1,745.92
|
|
|
MATERNITY LEVEL 4 PER 15 MIN
|
Facility
|
IP
|
$2,739.00
|
|
| Hospital Charge Code |
36001266
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$821.70 |
| Max. Negotiated Rate |
$2,629.44 |
| Rate for Payer: Aetna Commercial |
$2,109.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,136.42
|
| Rate for Payer: Cash Price |
$1,369.50
|
| Rate for Payer: Cigna Commercial |
$2,273.37
|
| Rate for Payer: First Health Commercial |
$2,602.05
|
| Rate for Payer: Humana Commercial |
$2,328.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,245.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,021.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$821.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,410.32
|
| Rate for Payer: Ohio Health Group HMO |
$2,054.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,191.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,382.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,889.91
|
| Rate for Payer: PHCS Commercial |
$2,629.44
|
| Rate for Payer: United Healthcare All Payer |
$2,410.32
|
|
|
MATERNITY LEVEL 4 PER 15 MIN
|
Facility
|
OP
|
$2,739.00
|
|
| Hospital Charge Code |
36001266
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$821.70 |
| Max. Negotiated Rate |
$2,629.44 |
| Rate for Payer: Aetna Commercial |
$2,109.03
|
| Rate for Payer: Anthem Medicaid |
$941.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,136.42
|
| Rate for Payer: Cash Price |
$1,369.50
|
| Rate for Payer: Cigna Commercial |
$2,273.37
|
| Rate for Payer: First Health Commercial |
$2,602.05
|
| Rate for Payer: Humana Commercial |
$2,328.15
|
| Rate for Payer: Humana KY Medicaid |
$941.94
|
| Rate for Payer: Kentucky WC Medicaid |
$951.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,245.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,021.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$821.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$960.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,410.32
|
| Rate for Payer: Ohio Health Group HMO |
$2,054.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,191.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,382.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,889.91
|
| Rate for Payer: PHCS Commercial |
$2,629.44
|
| Rate for Payer: United Healthcare All Payer |
$2,410.32
|
|
